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Improving Public Health Through State Health Improvement Planning: A Framework for Action

Marshall, Donna BSN, ASQ-CMQ/OE, ASQ-CQIA; Pyron, Trina MA; Jimenez, Jennifer MPH; Coffman, Joya MS, CHES; Pearsol, Jim MEd; Koester, Deb DNP, MSN, RN

Journal of Public Health Management and Practice: January/February 2014 - Volume 20 - Issue 1 - p 23–28
doi: 10.1097/PHH.0b013e3182a5a4b8
Accreditation Research

Background: State health improvement plans (SHIPs) identify priorities for making the greatest impacts on health promotion and disease prevention, specific to the needs of state populations. Both SHIPs and the state health assessments on which they are based are prerequisites for Public Health Accreditation Board national accreditation.

Objective: To identify and evaluate existing SHIPs to develop guidance to support health departments in the state health improvement planning process.

Design: In 2010, the Association of State and Territorial Health Officials (ASTHO) conducted a comprehensive search for existing SHIPs. A systematic evaluation of existing SHIPS was accomplished by means of primary source document review using a standardized data collection form. Using data derived from these SHIPs and guidance from a workgroup of practitioners, ASTHO developed the ASTHO SHIP Guidance and Resources (SHIP Guidance) Framework.

Results: The search yielded 25 states (49%) having a SHIP completed or in progress. Fifteen states (29%) had no SHIP but had a Healthy People plan, and 10 states (20%) had no SHIP or Healthy People plan. No information was available for 1 state. Findings were reviewed, evaluated, and incorporated into the SHIP Guidance. The SHIP Guidance provides a framework for the implementation, monitoring, and evaluation of a SHIP process using 12 key steps.

Conclusions: As public health/health care integration and accreditation readiness activity grows, multisector engagement through a SHIP will continue to be a priority for state public health and improving health outcomes. The SHIP Guidance provides a systematic, flexible approach for states conducting or updating state health assessments and SHIPs.

This article describes the key findings from an assessment of state health improvement plans and how these findings contributed to the development of a guidance framework for state health improvement planning.

Performance and Quality (Ms Marshall), Performance Improvement (Ms Coffman), and Public Health Performance Team (Mr Pearsol), Association of State and Territorial Health Officials, Arlington, Virginia; Division of Public Health Performance Improvement (Ms Pyron) and Carter Consulting, Inc (formerly Purdue Healthcare Advisors) (Dr Koester), Office for State, Tribal, Local and Territorial Support, Centers for Disease Control and Prevention, Atlanta, Georgia; and Public Health Accreditation Board, Alexandria, Virginia (Ms Jimenez).

Correspondence: Donna Marshall, BSN, ASQ-CMQ/OE, ASQ-CQIA, Association of State and Territorial Health Officials, 2231 Crystal Dr, Ste 450, Arlington, VA 22202 (

This work was supported by the Centers for Disease Control and Prevention (CDC) and the Association of State and Territorial Health Officials (ASTHO). The content is solely the responsibility of the authors and does not necessarily represent the official views of the CDC. Additional acknowledgement for invaluable contributions is made to the ASTHO State Health Improvement Planning Guidance and Resources Advisory Group, the ASTHO Survey Research Team, the CDC National Public Health Improvement Initiative evaluation team, Kentucky Department of Public Health, Missouri Department of Health and Senior Services, Montana Department of Public Health and Human Services, and Purdue Healthcare Advisors.

The authors declare no conflicts of interest.

A state health improvement plan (SHIP) is intended to provide leadership, direction, and oversight for the development of a statewide approach to engaging public health system partners in addressing the health of a state's population efficiently and effectively.1 , 2 By undergoing a state health improvement process, which includes a state health assessment (SHA) and leads to the development and implementation of a SHIP, state organizations enhance their capacity to address and monitor priority health issues impacting their populations. Effective SHIPs also have the potential to strengthen statewide public health delivery systems, enhance public health system leadership and infrastructure, and influence major health outcomes using population-based strategies.3–5

As a prerequisite for state health departments seeking national public health accreditation by the Public Health Accreditation Board (PHAB), SHIPs and the SHAs on which they should be based demonstrate meaningful use of the public health system and population health data to inform policy and translate priorities into evidence-based improvements in public health practice.3 , 6 , 7 While SHIPS are necessary to meet PHAB accreditation standards, they are ultimately intended to impact health outcomes. Conducting SHA and SHIP processes enables states to more clearly understand population health status and the factors contributing to health issues and to develop a systematic plan, including the assets and resources needed, to address those issues.1

In the PHAB Standards and Measures, Version 1.0, Standard 5.2 requires health departments to “conduct a comprehensive planning process resulting in a tribal/state/community health improvement plan.”1 For states, the measures associated with this standard address the state-level health improvement plan development process, the plan itself, implementation strategies, and evaluation.1 As defined in PHAB's Acronyms and Glossary of Terms, Version 1.0, a SHIP is a “long-term, systematic effort to address public health problems on the basis of the results of state health assessment activities and the state health improvement process.”8 PHAB Standards and Measures, Version 1.0, also require that a SHIP be based on the SHA and be linked to the state health department's strategic plan.1

As the national nonprofit organization representing state and territorial public health departments, states frequently request assistance from the Association for State and Territorial Health Officials (ASTHO) on methods, tools, and resources in preparing their agency staff for accreditation. One of the key objectives of ASTHO's accreditation support for state health departments is to provide comprehensive technical assistance and increase performance improvement activities, including the development of SHAs and SHIPs. The Centers for Disease Control and Prevention (CDC) has also prioritized performance improvement in states through the National Public Health Improvement Initiative and other programs and grant funding leading to further development of health assessments, health improvement plans, and strategic plans—all prerequisites for PHAB accreditation.9 State health departments that receive funding from the CDC for the National Public Health Improvement Initiative have been encouraged to develop a SHA and a SHIP as part of their grant activities. In addition, recent Internal Revenue Service community benefit requirements dictate that all tax-exempt hospitals develop a community health needs assessment, which may include state health department policy and health data input.10 Because of these initiatives, ASTHO has observed a growing interest from states in practical guidance on the process for developing, implementing, and monitoring a SHIP.

To better understand existing SHIPs and develop guidance for state health departments, a study, “ASTHO 2010 Evaluation of State Health Improvement Plans,” searched for and evaluated existing SHIPs (unpublished data, 2010). This article describes the key findings from that evaluation and how these findings contributed to the development of a guidance framework for state health improvement planning.

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In 2010, ASTHO conducted the “ASTHO 2010 Evaluation of State Health Improvement Plans,” in collaboration with Purdue Healthcare Advisors and with funding support and participation by the CDC Office of State, Tribal, Local and Territorial Support, to search for and evaluate existing SHIPs among all 50 states and the District of Columbia (n = 51). States were categorized on the basis of the SHIP status as follows: (1) having a current SHIP, (2) being “in process” of creating a new or updated SHIP, (3) having a Healthy People plan but no SHIP, or (4) having no SHIP and no Healthy People plan. A current SHIP was defined as a plan developed within the past 5 years and defined by the respective state as the SHIP.

A stepwise approach to retrospective SHIP review was developed to extract data effectively and systematically. Steps consisted of development of a conceptual formulation and vetting to generate clear data collection points, conducting a literature review on state health improvement planning, data abstraction instrument development, development of protocols and guidelines for abstraction of data from SHIPs, and data abstraction by trained staff. To ensure interrater reliability, 2 abstractors collected data on each SHIP and specific protocols were followed to resolve ambiguous or conflicting data. The evaluation was conducted using data extraction from individual SHIPs obtained from each state, as primary source documents; for states “in process” of completing a SHIP, individual, structured interviews were conducted with an individual designated by a state public health department in lieu of data abstraction. For each state having a SHIP, data collection included plan characteristics (eg, length of planning process, length of written plan, and the number of years over which the plan was to be implemented), assessment data used, state partners involved in planning, structure of the planning process, how priorities were established, plan implementation and dissemination, and alignment with national health priorities. All findings were summarized in a final written report, containing results for each category of states as described earlier.

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The “ASTHO 2010 Evaluation of State Health Improvement Plans” found 15 states (29%) having an existing, current SHIP; 10 states (20%) were in process of developing a SHIP; and 25 states (50%) having no current SHIP (15 of the 25 had a Healthy People plan they did not consider to be their SHIP). No information was available for 1 state. Findings of the 15 states having current SHIPs are reported here.

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Plan characteristics

Systematic review of the 15 SHIPs yielded findings that reflected wide variation of health assessments, improvement plans, planning processes, partners involved, and selected priorities. A state mandate for regular update of a SHIP existed in 86.7% of the 15 states having a SHIP. The length of the planning processes ranged from 8 to 48 months; duration of plan implementation ranged from 2 to 10 years, with an average of 3.9 years; and written plans were 1 to 345 pages in length.

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Using the PHAB Standards and Measures (beta version for state departments of health), a series of questions was developed to capture the types of assessment data that informed SHIP processes. These categories of data provided a measure of how well data used in SHAs and SHIPs aligned with proposed guidelines for accreditation. Data used in all reports were current. Eleven of the 15 plans (73%) used data describing the prevailing health of the state population. The most commonly used types of data included population health status, maternal child health, chronic disease, and vital records data (Figure 1). Least commonly used data included National Public Health Performance Standards, outbreak after action reports, Community Health Status Indicators, Youth Risk Behavioral Surveillance Survey, and Pregnancy Risk Assessment Monitoring System data. One state did not provide a description of the health data collected; however, reference was made to examining numerous health conditions and risk factors.



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Ten of the 15 plans (67%) included a list of the public health system partners involved in SHIP development. Partners most often included were academic partners, physicians, hospitals, environmental health, nonprofit organizations, and local health departments (Figure 2). Those least often included were correctional facilities, faith-based organizations, fire, law enforcement, media, neighborhood organizations, long-term care, and transit/transportation.



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Planning processes

Seven of the states (47%) with current SHIPs included a description of the planning process. The size of the “executive planning” or “steering committee” (various terms used) ranged from 20 to 76 members. The number of individuals involved in the overall planning process (work groups etc) ranged from 40 to more than 400. The frameworks used in planning processes varied from state to state. Three of the 15 states with SHIPs (20%) received technical assistance from another source to complete their SHIP process. Plans were also analyzed to determine whether they established improvement strategies and performance measures. Thirteen plans (87%) included improvement strategies, 9 plans (60%) included performance measures, and 9 plans (60%) included state policy changes needed to achieve objectives.

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Of the 15 SHIPs, 11 (73%) identified a set of priority health issues and 13 (87%) identified a set of infrastructure or public health system improvement priorities. Plans were also analyzed to determine whether they established state priorities that aligned with national health priorities using the 2010 CDC winnable battles. Thirteen plans (87%) identified nutrition/activity/obesity as a priority health issue, 9 (60%) identified tobacco, 6 (40%) identified teen pregnancy, 4 (27%) identified HIV/AIDS, 3 (20%) identified motor vehicle accidents, and 1 (7%) identified health care–acquired infections as a priority issue.

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Using the evaluation findings, the ASTHO SHIP Guidance and Resources (SHIP Guidance) framework was developed. Members of an expert advisory group were selected on the basis of their experience with health improvement planning to inform development of the SHIP Guidance and ensure a useful product for state health departments. The advisory group, composed of representatives from ASTHO, CDC, and 7 states, was led by staff from ASTHO and the CDC Office of State, Tribal, Local and Territorial Support. The document is laid out in 12 key steps, providing a framework for development, implementation, and monitoring of a SHIP (Figure 3). Some or all of these steps may be used depending on a state's needs and whether a SHA has been completed. Within each of the 12 steps are 5 recurring sections to facilitate understanding and implementation: Description, Link to PHAB, Steps (action steps for each component), Tips, and Examples/Resources.



Those familiar with the Mobilizing for Action through Planning and Partnerships (MAPP) framework will notice that many components described in the SHIP Guidance align with those of MAPP.11 This alignment was intentional, as the advisory group agreed that using a MAPP-like approach was a valuable way to develop a SHIP. While the MAPP model is an improvement process for local public health systems, it can be adapted for use at the state level and where appropriate, the SHIP Guidance includes state-level examples to emphasize this. Findings from the “ASTHO 2010 Evaluation of State Health Improvement Plans” final report (unpublished data, 2010) are included throughout the SHIP Guidance, with examples and links to additional resources.

The SHIP Guidance is currently used by state health departments interested in developing a comprehensive, inclusive, and robust health improvement plan that adheres to the guidance provided in the PHAB Standards and Measures, Version 1.0. To date, the SHIP Guidance has been distributed to the health official in every state and territory and is featured on the ASTHO Web site. Multiple requests for the SHIP Guidance have been received by states to inform their SHIP development and implementation process. For example, in Missouri, the SHIP Guidance was used as the framework for the completion of the SHA and SHIP and was found to be valuable in identifying partners in planning, outlining clear deliverables for both the state health department and the contractor facilitating the process, and development of a budget for the process. In Kentucky, the SHIP Guidance was used as a resource by the state health department during its health improvement planning process to ensure diversity of stakeholders. In Montana, the SHIP Guidance was used for understanding the development and implementation process, establishing the planning process for identification of partners and their roles, and prioritizing health issues.

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There are a few limitations regarding the data and framework presented in this article. While all data collection was conducted in a standardized manner, it should be acknowledged that the responses reported are only as accurate as the available documentation and state responses. Every effort was made to enable states to provide the most current and accurate information for the evaluation. Second, there has been no formal evaluation of the SHIP Guidance to fully assess its validity. Finally, as a stand-alone document, the SHIP Guidance represents only one approach to health improvement planning in states and permits implementation and application in a manner that is unique to each state health agency.

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A SHIP is critical for developing policies and defining actions to target efforts that promote health. It should define a vision for health through a collaborative process and should address the strengths, weaknesses, challenges, and opportunities that exist to improve health status. A SHIP provides leadership, direction, and oversight in a state to address health improvement, strengthens public health infrastructure, and engages system partners in contributing to planning, implementation, and evaluation—all key characteristics of PHAB accreditation. It also provides information on health status, system capacity and resources, health improvement policy options, health and system priorities, measurable objectives and outcomes, implementation plans, and evaluation measures, all within established time frames. To conform with PHAB standards, state health departments must include all of these components in their SHIP, which can help improve the health of the state's population. The SHIP Guidance takes these characteristics and components and applies them in a step-by-step process for developing, implementing, and monitoring a SHIP effectively.

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1. Public Heath Accreditation Board. Standards and Measures, Version 1.0. Standards and Measures. Accessed January 9, 2013.
2. US Department of Health and Human Services. Consensus Statement on Quality in the Public Health System. Accessed January 9, 2013.
3. Institute of Medicine. Improving Health in the Community. Washington, DC: National Academies Press; 1997.
4. Metzger M, Alexander J, Weiner B. The effects of leadership and governance processes on member participation in community health coalitions. Health Educ Behav. 2005;32(4):455–473.
5. Roussos S, Fawcett S. A review of collaborative partnerships as a strategy for improving community health. Annu Rev Public Health. 2000;21:369–402.
6. Institute of Medicine. The Future of the Public's Health in the 21st Century. Washington, DC: National Academies Press; 2003.
7. Brownson R, Gurney J, Land G. Evidence-based decision making in public health. J Public Health Manag Pract. 1999;5(5):86–97.
8. Public Health Accreditation Board. Acronyms and Glossary of Terms. Accessed January 9, 2013.
9. Centers for Disease Control and Prevention. National Public Health Improvement Initiative. Accessed January 9, 2013.
10. Internal Revenue Service. New requirements for 501(c)(3) Hospitals Under the Affordable Care Act. Accessed January 15, 2013.
11. National Association of County and City Health Officials. Mobilizing for Action through Planning and Partnerships: Web-based tool. Accessed January 15, 2013.

health improvement planning; national accreditation; SHIP Guidance and Resources; state health improvement planning

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